Every finding on record at Rogue River Healthcare LLC

An unannounced Federal recertification survey was completed at this agency on 3/10/2022. The agency was surveyed for compliance with 42 CFR Conditions of Participation for Home Health Agencies, Part 484. An entrance conference was held with the Executive Director on 2/28/2022 at 1:20 PM. The purpose of the survey and the survey needs were explained. An opportunity was provided for questions, answers and comments. Definitions and abbreviations: CFR - Code of Federal Regulations HFA - hydrofluoroalkane, a propellant used in metered dose inhalers mcg - microgram mg - milligram prn - as needed

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review and interview, it was determined the agency failed to ensure the individualized plan of care included complete medication orders for 2 of 12 active patient clinical records reviewed (Patients #5 and 6). Patient #5: Review of the "Home Health Updated Plan of Care Report" for the certification period from 2/9/2022 to 4/9/2022 revealed the order "Acetaminophen 500 mg tablet, 2 tablet, oral, as needed, Reason: pain." The order failed to include the frequency the medication could be taken. Further review of the "Home Health Updated Plan of Care Report" revealed the order "Albuterol Sulfate HFA 90 mcg/actuation, 2 puff, inhalation, as needed, Reason: breathing." The order failed to include the frequency the medication could be taken. Further review of the "Home Health Updated Plan of Care Report" revealed the order "Clonazepam 0.5 mg disintegrating tablet, 0.5 tablet, oral, as needed, Reason: anxiety." The order failed to include the frequency the medication could be taken. Patient #6: Review of the "Home Health Updated Plan of Care Report" for the certification period from 3/1/2022 to 4/29/2022 revealed the order "Loperamide 2 mg tablet, 2 tablet, oral, as needed, Reason: diarrhea." The order failed to include the frequency the medication could be taken. During an interview with Employees #1, 2, 3, 4 and 5 on 3/9/2022 beginning at 1:00 PM, the above findings were presented. Employee #1 acknowledged the findings that the orders were incomplete and stated "I agree that the prn medications should have parameters attached to them."